A week or two back the headlines shouted that nearly one in three of those dying in hospital were the victims of euthanasia on the quiet. And the culprit was the Liverpool Care Pathway (LCP) – a sinister routine designed to hasten the sick and old to an early death from over-drugging and refusal of nutrition and hydration, thus freeing up a bed for the next victim. Why go to Switzerland when you can have death free on the NHS?

So let’s just have a look.

It is broadly accepted that the best chance of a peaceful death is to be in a hospice or, failing that, nursing at home with the assistance of hospice outreach. Hospital deaths appear to be the least satisfactory because a hospital is geared to healing, and may not be in a position to provide the best care. A depressing recent survey by the Office of National Statistics confirms that this is perceived to be so (link below). The LCP was designed to help bring the care of the dying in any institution up to the standards of best hospice care.

The protocols are quite detailed. They cover the diagnosis agreed by the multidisciplinary team, the care plan to be followed, a regular check routine, the appropriate medical and nursing information, pain control, provision of spiritual care, communication with the patient and the patient’s family, and informing the GP (link below).

The LCP has been recommended by the Department of Health as the best model for care of the dying. It is audited regularly. This shows a broadly satisfactory but somewhat uneven picture (link to 2011/12 audit below).

The protocol observes the moral principle of double effect that evil may not be done in order that good should be achieved. So we must not shorten life in order to bring about what, from our point of view, we may see as a quicker and so happier death. By the same principle we can, for example, reduce a patient’s pain even though the treatment may incidentally risk shortening of life, provided that the two ends are proportionate.

The criticisms launched at the LCP are understandable. The prediction of death is always uncertain and, although the LCP can and should be reversed as soon as the patient shows the possibility of recovery, this will be difficult to detect in the case of, say, a sedated patient. So the protocol requires a careful investigation of all the possibilities beforehand.
There is also concern about the withdrawal of nutrition and hydration. Surely, it is argued, these are natural needs and to withdraw them would be tantamount to taking life. But, surprisingly to us lay folk, at the last stages of life the system is closing down – and this withdrawal avoids imposing an increasing burden. But withdrawal should be the last resort (Royal College of Physicians, 2010).

The quoted figure that 29 per cent of hospital deaths have occurred to patients on the LCP has been interpreted by some as evidence that all these patients have been deliberately hastened to early deaths. But where the LCP has been conscientiously followed this would not be the case; it is gratuitous to claim otherwise. I have seen no credible estimate of the percentage of cases in which the LCP has been abused. I am happy to quote from Fr James Mulligan’s article in this paper in April 2010: “My own experiences of the LCP, from the perspective of hospital chaplain, have been very positive. I have certainly not found the heartless, box-ticking approach allegation to have any foundation. In fact, the opposite. I have been very impressed with how each patient is accorded dignity as an individual and how much the LCP carers strive to look after often the most idiosyncratic of needs.”

It would be naïve to suppose that abuses, perhaps amounting to euthanasia, do not occur – even if we cannot document them or be sure of the scale. Inevitably some medical staff will genuinely believe that a patient would be better served by accelerating his end. Others will allow the pressures of medical demands to distract them from the protocols. For example, a doctor might take a decision on his own without consulting the rest of the team or checks on patient who is on the Pathway might be too cursory to be reliable. Nor do I discount the possibility that the temptation to clear a much-needed bed will influence, perhaps subconsciously, the decisions made. It is certainly enough of a danger to be wary.

The best strategy for the next of kin, or the patient, if capable, is to be curious. You should show a lively interest about what is happening and intended, and state clearly that you would like to be informed before a decision is made. Ask questions. Medical staff who are proud of their care for the dying will be very willing to explain the reasons for their proposed decision, and to tell you how they will check for signs of recovery. I would ask to see the hospital protocol forms because it would give me a basis for questions (link to an example below). While the responsibility for care, in accordance with the best interests of the patient, remains with the doctor, you can always ask for a second opinion. And you should certainly do so if your questions have not been answered willingly, or you suspect that the protocol is not being followed correctly.

My thanks to Dr Trevor Stammers, programme director in bioethics and medical law at St Mary’s Twickenham, for his assistance. Any mistakes or misinterpretations are mine, not his.

LINKS (If you want to open the link in a new tab, copy and paste the link below into a new tab on your browser.)

22 Responses to How they die in Liverpool

I am heartened by Fr Mulligan’s description of LCP as quoted in this blog. However the quotes and other directives are already a couple of years old and I wonder what is the situation today.
Regrettably we all have examples of how the careful use of language creates one picture when the actual evidence can dictate something else. ‘Women’s Rights’ and ‘My body, my choice’ etc. instead of ‘killing the unborn child’ being such an example. So when you read the word’s ‘care’ and ‘pathway’ that conjure up a picture of a gentle drift from this life to an almost pleasurable end then is this a reality or illusion for what is a painful death where any suffering that ensues will be of no consequence once death has occurred.
Euthanasia, ‘dying with dignity’ and ‘mercy killing ‘ ( language again,) have become respectable options over the last few years with many a campaigner promoting them. A short step from preservation of life being the ideal to the taking of life being the actual policy.

Oddly enough someone was telling me only last week how he had just observed the LCP at close hand. His family had been through it with their dying mother and just come out the other side. He was moved by the whole business and the family had felt included as decision makers not as mere onlookers.

This post reminds me of a time in the early ’50s when I was resident at a small local hospital. In those days the resident was in charge 24/7 and support was provided by local GPs (daily visits) and consultants (approx weekly).
I had a patient with severe and extremely painful cancer and I was prescribing 4 hourly doses of morphia – many times the usually accepted dose.
Matron approached me to say that “this is very bad for the nurses!” I replied that I was simply trying to give this man some relief from pain – I knew that this dosage was potentially lethal and would probably shorten his life, but nevertheless I felt it justified to relieve his pain.
I know very little about the LCP and I have only scanned Quentin”s links very quickly but it seems to be an elaboration of just this philosophy – although the number of boxes to be ticked is truly astounding!
I assume that this approach is taught in Medical schools today. I shall try to read the links more carefully and will be most interested in other comments.

Quentin, wasn’t there an article in the CH a few weeks ago which was highly critical of the LCP? It would appear that physicians who have doubts about it are not necessarily Catholic or even Christian. When I am in extremis I don’t want anything to do with Liverpool. The idea of my Requiem Mass celebrated in the Mersey Funnel would have me pin-wheeling in my grave.

Yes, it was the story behind 23 June article which led the Editor and me to try and bring a better balanced point of view — which I hope I have. Incidentally Lady Finlay (the expert in palliative care) told me that doctors were nervous about using morphine to quell pain; at that time they needed better education in effective dosages. My mother died in 1959, in a Catholic hospital. My father had to decide whether she should be given more morphine, even though this would incidentally shorten life. He consulted his children, and said yes.

I just find when we are putting things like Euthanasia, Abortion, Mercy Killing, and the likes just How detatched we all are? It is truly apalling.
As we are detatched from life, so are we detatched from death.
Ok, one can wax philosphical, theological, be dogmatic and so on but being detatched from life and death means we are dead while we live out our lives physically.
Being dead while we live, such things as people being murdered, aborted by the millions around the world daily, and people choosing death rather than life, is all just ideas in one head with no real understaning of either.
If we have not loved we have not lived, if we have not lived but are dead while we live, the idea of choice by the patient’s or the relatives or the medical people to end someones life prematurely,
is detatched and meaningless.

The significance of live is as important as the significance of death.
Consider if you will, death will be for you and I something extraordinary, something you cannot think about, live with yes, but cannot think about it, because it lies beyond our thoughts.
The nearest we get to a process of dying in this life, which is equally a death, is death to Self.

Whether one is religious or not, the desire to live is always there in the brain and the physical life.
Choosing death is a silly argument, because as I have pointed out, out thoughts on the matter are detatched, meaningless and we cannot think about our own death at all, it is unknown to us, and beyond our thinking.
The only way we see death is by association, a dead tree, animal, flower, fish, or a human corpse,
but I defy these death merchants, medical, philosophical nutcases for death will defy any intellectual inquiry.

It seems that George V was killed by his physician (Lord Dawson) so that his death could be announced in the morning rather than the evening papers. Apparently he had few qualms about euthahasia, as evidenced by the rhyme:

I have been thinking about the LCP and reading Quentin’s linked documents.

One thing that strikes me straightaway is the remark
” . . a hospital is geared to healing”.
In a sense this is obvious, but on thinking about it, in my day the emphasis was more on care. Apart from obvious things like repairing fractures and wounds and some surgical procedures like appendicectomy there was not a lot of specific ‘healing’ that could be done.
Today things are different and I read (in ‘Information for Healthcare Professionals’) “the LCP is a means to empower healthcare professionals by winning time in the climate of “busyness” to enable best practice in the last hours or days of life”.
In other words – because today a hospital is a very different place, with complex surgical procedures on the one hand and equally complex medical treatments on the other, a patient who is dying, and for whom nothing further can be done by way of ‘healing’, is low on the priority list and tends to be simply neglected.

There is, incidentally, as far as I can see from reading these documents, no way that the LCP could be used as an excuse for euthanasia – except through culpable ignorance or deliberate criminal obfuscation.

Horace,
I think you are right about that. I’m in hospitals quite a lot through volunteer chaplaincy and see that busyness, often thinking to myself:
“there is no place to die in here”
We have a hospice of course but I guess there isn’t room for everybody.

Dear Fellow bloggers
This just goes to how detached we are not oly from others but fromlife and death.
This arrived on my computer today.

When an old man died in the geriatric ward of a nursing home in an Australian country town, it was believed that he had nothing left of any value.
Later, when the nurses were going through his meagre possessions, They found this poem. Its q…uality and content so impressed the staff that copies were made and distributed to every nurse in the hospital.

One nurse took her copy to Melbourne. The old man’s sole bequest to posterity has since appeared in the Christmas editions of magazines around the country and appearing in mags for Mental Health. A slide presentation has also been made based on his simple, but eloquent, poem.

And this old man, with nothing left to give to the world, is now the author of this ‘anonymous’ poem winging across the Internet.

Cranky Old Man

What do you see nurses? . . .. . .What do you see?
What are you thinking .. . when you’re looking at me?
A cranky old man, . . . . . .not very wise,
Uncertain of habit .. . . . . . . .. with faraway eyes?
Who dribbles his food .. . … . . and makes no reply.
When you say in a loud voice . .’I do wish you’d try!’
Who seems not to notice . . .the things that you do.
And forever is losing . . . . . .. . . A sock or shoe?
Who, resisting or not . . . … lets you do as you will,
With bathing and feeding . . . .The long day to fill?
Is that what you’re thinking?. .Is that what you see?
Then open your eyes, nurse .you’re not looking at me.
I’ll tell you who I am . . . . .. As I sit here so still,
As I do at your bidding, .. . . . as I eat at your will.
I’m a small child of Ten . .with a father and mother,
Brothers and sisters .. . . .. . who love one another
A young boy of Sixteen . . . .. with wings on his feet
Dreaming that soon now . . .. . . a lover he’ll meet.
A groom soon at Twenty . . . ..my heart gives a leap.
Remembering, the vows .. .. .that I promised to keep.
At Twenty-Five, now . . . . .I have young of my own.
Who need me to guide . . . And a secure happy home.
A man of Thirty . .. . . . . My young now grown fast,
Bound to each other . . .. With ties that should last.
At Forty, my young sons .. .have grown and are gone,
But my woman is beside me . . to see I don’t mourn.
At Fifty, once more, .. …Babies play ’round my knee,
Again, we know children . . . . My loved one and me.
Dark days are upon me . . . . My wife is now dead.
I look at the future … . . . . I shudder with dread.
For my young are all rearing .. . . young of their own.
And I think of the years . . . And the love that I’ve known.
I’m now an old man . . . . . . .. and nature is cruel.
It’s jest to make old age . . . . . . . look like a fool.
The body, it crumbles .. .. . grace and vigour, departI once had a heart.
But inside this old carcass . A young man still dwells,
And now and again . . . . . my battered heart swells
I remember the joys . . . . .. . I remember the pain.
And I’m loving and living . . . . . . . life over again.
I think of the years, all too few . . .. gone too fast.
And accept the stark fact . . . that nothing can last.
So open your eyes, people .. . . . .. . . open and see.
Not a cranky old man .
Look closer . . . . see .. .. . .. …. . ME!!

On the other hand, ‘Care Not Killing’ believes the protocol is reasonable and proper, as well as better than what might happen if individual doctors were left without guidance. See for example the endorsement of Dr Peter Saunders, who is no wet liberal.

This is not an easy call, but respected anti-euthanasia campaigners such as Dr Saunders and Baroness Finlay are not concerned.

There is every reason to worry about current campaigns to legalise euthanasia – supported by Lord Falconer’s hand-picked ‘commission’ and Tony Nicklinson’s High Court case. These are much more important than the Liverpool Pathway. The BBC repeatedly issues propaganda for euthanasia (ignoring WHO guidelines as well as the normal requirements of balance in reporting controversy). Concentrate on these campaigns. Every time you see a BBC report favoring euthanasia, write or ring them and complain!

I have only just got around to reading the current issue of the Catholic Herald and I find the following in an article by Simon Caldwell:-
“Under the LCP patients considered to be close to death are heavily sedated then denied any artificial nutrition or hydration, which since the Bland judgement of the 1990s is classed as treatment.”

Either what I have read, in Quentin”s links and other places on the internet, is totally wrong or this is arrant nonsense!

The following are contradicted by clear statements in the definition of the LCP.
[“What is the Liverpool Care Pathway for the dying patient(LCP)?
Information for Health Care Professionals] :-

⚫ Under the LCP patients considered to be close to death are heavily sedated
“The LCP does not recommend the use of continuous deep sedation.”
⚫ then denied any artificial nutrition or hydration
“The LCP does not preclude the use of artificial hydration.”

It is worth noting that later Caldwell quotes Lord Phillips “any doctor who deliberately brings that patient’s life to an end by discontinuing the supply of ANH (assisted nutrition and hydration) will not merely be in breach of duty but guilty of murder”.

The paragraph that I quoted above may indeed be “some opinions expressed by others” but this is nowhere indicated as such in the text or attributed in any clear way.
Furthermore it may indeed be true – in the sense that it might, for example, have been intended to imply :-
“Some physicians use the term “LCP” to designate a philosophy of treatment by which patients considered to be close to death are heavily sedated . . . etc.”

I note that in the TEWV Guidelines :- “Practitioners are free to exercise their own professional judgement, however, any alteration to the practice identified within this LCP must be noted as a variance on the sheet at the back of the pathway.” and this, together with the exhaustive ‘box-ticking’ notes should make it easily possible to identify any such practices unless, of course, there is “deliberate criminal obfuscation”.

I still notice we are not coming to the point on all this issue of Euthanasia.
Turn your television or radio on, pick up a newspaper any day you like, and we see or have reported or read of murders, wars rapes, kidnapping and so on, yet we hardly give it a passing thought.
It is not happening to you or your family, and God forbid that it ever should, but when it comes
to Euthanasia or assisted suicide, here is a big outcry. Why?

Do we see that life and death are one? There is the beginning, our birth, growing up, marrying, having children, retiring, and growing old…leading to death, it is all one process.
Medical interventions can prelong life, certainly, but the cry for assisted suicide seems to be getting more prevalent as the years go by. What would account for this? Where did the idea of euthanasia originate?
Those who would want euthanasia legalized have not understood the significance of life and so teminating anothers life they have not understood death either. That is why it is a dangerous road to go down.
In not understanding life leading to death, those death merchants have not understood how important the whole process of dying is for everyone.
If we have understood life, then we know that this body and metabolism is coming to an end.
In dying there is the process of ending all our attachments, all our antagonisms, hatred, fears
and the continuity of life is ending. When a person understands this, they are living side by side with death, which is an extraorinary thing to do. There is neither past or present or future, there is only the ending.
Euthanasia stops the person whose life is nearing its end, naturally, to actually let go. Forcing or hastening the death of another, as I have said, those who propose such a thing as euthanasia have not understood life let alone what it is to die.

Quality control issues seem to be one of the most important considerations in ‘How they Die in Liverpool’. Apart from the curiosity of the patient and his/her relatives and friends, it is important to examine how, as a society, we can watch those who watch over us. How can we adequately supervise the supervisors? The very same issue confronts all democratic societies with regards their police forces. Who polices the police? How adequately staffed and funded are they, and are they at arm’s length of the police force that they supervise?

Similar considerations apply to whatever key performance indicators (PKIs) are spelt out for the protocols or standards of care of the Liverpool Care Pathway or LCP. How can the society of the UK be relatively sure and confident that the LCP will be followed by medical and nursing staff at all times, and especially when some medical staff is under pressure?

I offer the following suggestion as a non-resident of the UK. I think it would be important to have an independent assessor or ombudsman if you like, which would be physically located in the patient standards or ethics section of a hospital, or independently employed by the Department of Health. Much like a public prosecutor, they would have complete independence under statutory authority, to initiate an investigation and offering their preliminary or final reports to a higher officer located in either the hospital or both the hospital and the Department of Health.

SecondSight has dealt with the issue of euthanasia in a general way in ‘Dealing with Dad’ back in February 2011. ‘Dealing with Dad’ is a good introduction to the topic of euthanasia and I would warmly recommend it to all readers as a backdrop to the issues under discussion in ‘How they Die in Liverpool’.

As I stated in ‘Dealing with Dad’, I strongly believe that Catholics, other Christians opposed to euthanasia, as well as people from other faiths such as the Muslim, Buddhist, and Jewish faiths who oppose euthanasia, will win this argument provided that it is adequately presented to the public. The basis of this confidence is that research in the medical speciality of Palliative medicine is ongoing and will gradually limit the number of individuals that have uncontrollable pain in their last days of life. When Palliative medicine has seriously limited (or eliminated?) the number of people who present with uncontrollable pain, it would be incumbent on both the medical profession, in peer reviewed journal articles, and the Church, to communicate such advances as soon as practicable to the media, the rest of society and most importantly, its parliamentarians.

I have neglected to add that any hospital based assessor that oversees any aspects of the LCP, and who has statutory independence, much like an ombudsman, can have other important functions apart from initiating independent inquiries. These include being a ready source of knowledge about any aspect of the LCP for both medical and nursing staff, any administrative staff at any hospital, any patient, and their relatives and friends.

When any medical or nursing professional or anyone else is in difficulty, they can always convey their concerns and questions to an LCP assessor, who can then offer them appropriate guidance on any applicable protocol or standard of palliative care. They could also possibly have the authority to randomly sit in any professional discussion amongst medical or nursing staff and offer their opinions on any aspect of the LCP. This would particularly be useful when complex patient circumstances are in play. These functions would certainly add a string to their bow and round out their professional role in palliative care.

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